Esophageal atresia: Primary repair of a rare long gap variant involving distal pouch mobilization

Davison, Patrick; Poenaru, Dan; Kamal, Ihab

doi:10.1016/s0022-3468(99)90340-8

Cited by 9 publications

(6 citation statements)

References 11 publications

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“…In patients with EA with a TEF, gap length is usually estimated during surgery, but this is not always consistent, because it is liable to change by the timing of estimation, for instance, before or after the proximal esophageal pouch is dissected. Moreover, there is no definitive international guideline and the timing of estimation is seldom recorded in the literature [1][2][3][4][5][6][7][8][9]. Therefore, gap length in published papers may be puzzling.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, gap length has been employed as a measure for selection of surgical procedures [1][2][3][4][5][6][7][8][9] and the term 'long gap' has been utilized for cases which do not allow primary anastomosis to be readily performed. However, definition of the long gap is not uniform in literature and there is no definitive guideline to estimate gap length.…”

Section: Introductionmentioning

confidence: 99%

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Proposal of a novel method to evaluate anastomotic tension in esophageal atresia with a distal tracheoesophageal fistula

et al. 2005

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Anastomotic tension with the potential to lead to post-operative complication is usually evaluated using gap length before anastomosis in patients with esophageal atresia and a distal tracheoesophageal fistula (EA with a TEF). However a uniform, accurate measurement of gap length is not possible and estimation of the length the delicate distal esophageal stump is stretched by the anastomosis may have greater utility. The aim of this paper was to propose a novel method to evaluate the anastomotic tension in EA with a TEF. Forty consecutive patients having EA with a TEF were studied. Primary anastomosis without gastrostomy was performed in all cases. When the TEF was cut off, the most proximal site of the tracheal side was marked using a tiny metallic clip. When anastomosis was completed, the distance from the clip to the anastomotic site was measured as the stretched length. On the esophagram taken subsequently, the same distance was measured, together with the distance from the clip to the esophago-cardiac junction as the original distal esophageal length. The stretching ratio was calculated by dividing the former by the latter. The stretched length on esophagram (median: 3.0 mm, range: -12 to 21) was significantly correlated with that measured during surgery (median: 2.3 mm, range; -14 to 15) (r = 0.96, P < 0.0001). The median of original distal esophageal lengths was 60.0 mm (range: 35-80). The stretching ratio was significantly correlated with the stretched length, and the number of the stretching ratio as a percentage corresponded to about double the number of the stretched length on esophagram in millimeters (y = 1.91x + 0.58, r = 0.98, P<0.0001). Anastomotic leakage and recurrence of TEF were not experienced. In patients complicated with gastroesophageal reflux (GER), the site of TEF was significantly more distal as compared with the other cases [median (range): 5.0th (4.0-6.0) vs 3.5th (1.5-5.0) thoracic vertebral level, P<0.009]. The stretched length and the stretching ratio were also longer and larger, respectively [median (range): 10.0 mm (6-21) vs 2.0 (-12 to 14) mm, P<0.008, 17.3% (12.7-47.7) vs 2.9% (-16.4 to 29.8)%, P<0.018). Similar tendencies were observed for patients complicated with stricture. Estimation of the stretched length of the distal esophageal stump is useful to evaluate the anastomotic tension. If the stretched length is more than 10 mm, it will be necessary to consider the possibility that stricture or GER may arise afterwards.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Proposal of a novel method to evaluate anastomotic tension in esophageal atresia with a distal tracheoesophageal fistula

et al. 2005

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“…1 Management of long-gap esophageal atresia in neonates is still a challenging problem and a topic of controversy among pediatric surgeons. [2][3][4][5][6] The best esophagus is the patient's own and, therefore, every effort should be made towards esophageal preservation by delayed primary anastomosis. It is generally agreed that the native esophagus is the best conduit for food and saliva, and numerous approaches have been described for the management of neonates with long-gap esophageal atresia.…”

Section: Discussionmentioning

confidence: 99%

“…2,6 Spontaneous growth and hypertrophy of esophageal pouches occur in the absence of any mechanical stretching and reach their maximum by the end of the first eight weeks of life, therefore, delayed primary anastomosis occurs usually after eight weeks of life. 2,7 However, the spontaneous growth sometimes of esophageal pouches is not enough to shorten the defect for primary repair, 4 therefore, a variety of adjuvant methods have been described to promote interim esophageal growth. 6,9 This new technique is easy to perform, easy to manage at home while waiting for repair, and also easy to follow up during the waiting period.…”

Section: Discussionmentioning

confidence: 99%

Passive Lengthening of the Esophageal Pouches in Long-Gap Esophageal Atresia: A Technical Innovation

Nour

2002

Ann Saudi Med

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There are many surgical procedures for the treatment of long-gap esophageal atresia, which are associated with different complications. In the passive lenghening of the esophageal pouch technique, one metallic or radio-opaque rubber ring is fixed to the blind end of each pouch, then a non-absorbable thread is fixed to the ring of the lower pouch, passed through the ring of the upper pouch, and finally fixed to the tip of a calibrated nasogastric tube (NGT) in the lower pouch. The NGT is anchored on the abdominal wall by a safety pin, and by gradual pulling of the NGT, lengthening of both pouches occurs. Determination of the degree of lengthening is easy and helps decide the time for the definitive repair. Saliva accumulation in the upper pouch can be managed at home by continuous Reblogle tube suction by keeping the patient in a prone head-down position, or by a combination of continuous Reblogle tube suction and oral suction dummy. MethodUnder general endotracheal anesthesia, with the patient in the left lateral position, right lateral extrapleural thoracotomy through the fourth intercostal space is performed. The azygos vein and posterior mediastinum should be exposed, so that both esophageal pouches and fistula are seen. The azygos vein is ligated and divided. The upper pouch is identified and dissected as much as possible to gain maximum length. The lower pouch is identified, and if a fistula is present, it has to be divided. Meticulous dissection of the lower pouch has to be done to gain the maximum length. Metallic or radiopaque rubber ring (stainless steel or titanium) is fixed, one to the end of each pouch with non-absorbable stitch. The ring is about 3 mm in diameter (Figures 1 and 2).Gastrostomy is to be done, one for feeding gastrostomy tube and one for calibrating the NGT, which is passed up the lower pouch up to its opened end, in the presence of a fistula or up to its blind end, where there is no fistula. In this case, it has to be opened to allow the NGT to come through its tip. The two pouches are anchored together by non-absorbable stitch with good tension. Using non-absorbable thread which is fixed to the ring attached to the lower pouch, it is passed through the ring fixed to the upper pouch and finally fixed to the tip of the NGT by the shortest length, which keeps the NGT pushing against the tip of the lower pouch. This will now be closed with a purse-string suture using non-absorbable thread. The gap between the ends of the two pouches can easily be measured intraoperatively.The calibrated NGT is anchored on the abdominal wall with a safety pin and the point of exit, for example, at the 10 cm mark on the NGT. The thoracotomy incision is then closed in layers without intercostal tube drainage.Passive stretching has to be done soon after surgery to avoid fibrous tissue formation around the pouches by pulling on the NGT, which will pull the lower pouch up and the upper pouch down, decreasing the gap. This maneuver has to be done twice weekly. After each setting, the NGT is anchored on the abdo...

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“…If that is the case, delayed primary anastomosis Original Article should be attempted. Most contend that the use of the native esophagus is superior to any interposition procedure (4) and that primary repair provides the best conditions for functional motility and good long-term outcome. Primary anastomosis can be achieved by various techniques, including bougie stretching, circular myotomy (6), continuous suture traction with reoperation, and proximal pouch flaps (7).…”

Section: Langstreckige öSophagusatresie´unteres öSophagussegmentd Urcmentioning

confidence: 99%

The Distal Pouch in Esophageal Atresia - To Dissect or Not to Dissect, That is The Question

Farkash

Lazar²,

Erez³

et al. 2002

Eur J Pediatr Surg

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Long-gap esophageal atresia remains a difficult problem for the pediatric surgeon and reconstruction using the native esophagus is considered to be superior to any interposition procedure. Because of esophageal segmental blood supply and vascular vulnerability of the distal esophageal pouch in the short term and its motility disorder in the long term, surgeons are reluctant to perform extensive esophageal dissection. However, ascending and descending branches of esophageal vessels converge along the anterolateral and posterolateral aspects of the esophagus. This arrangement allows for dissection and mobilization of the distal pouch without necessarily causing vascular impairment. Extensive dissection of the distal pouch was advocated by Robert Gross over fifty years ago. More recently, circular myotomy of the distal pouch has been performed. However, manometric studies showed that prior to surgical repair, peristalsis of the upper and lower esophageal pouch was synchronized, while after surgery this coordination was clearly defective. Furthermore, in the adriamycin-induced rat model, inherent abnormalities in the course and branching pattern of the vagus nerves in the lower esophagus have been demonstrated. Significant abnormalities of the intramural nervous components involving both the excitatory and inhibitory nerves, and elevated levels of S100 and galanin in the lower esophageal pouch could explain an inborn motility disorder. The selective injury of minor vagal branches in experimental animals also alters esophageal peristalsis. In conclusion, given that the native esophagus is still considered the best alternative for reconstruction of esophageal atresia, when indicated, gentle but extensive dissection of the lower esophageal pouch seems to be preferable, keeping in mind the possibility of vascular compromise and the inevitability of motility disfunction.

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Esophageal atresia: Primary repair of a rare long gap variant involving distal pouch mobilization

Cited by 9 publications

References 11 publications

Proposal of a novel method to evaluate anastomotic tension in esophageal atresia with a distal tracheoesophageal fistula

Proposal of a novel method to evaluate anastomotic tension in esophageal atresia with a distal tracheoesophageal fistula

Passive Lengthening of the Esophageal Pouches in Long-Gap Esophageal Atresia: A Technical Innovation

The Distal Pouch in Esophageal Atresia - To Dissect or Not to Dissect, That is The Question

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